Riding the Line Between Pain Management and Opiate Addiction

Roberta remembers riding a bike. She shares this memory with Celina Ramirez, her CHCN Care Neighborhood case manager, during a home visit. Fresh valentine flowers from her husband grace the sideboard. Her Chihuahua mix puppy is upstairs, “So he doesn’t jump all over you.” Celina asks Roberta about her medications. A flicker of dismay crosses Roberta’s face, as she’ll have to climb the stairs again to retrieve them. But she prides herself on staying on top of her pill regimen. She wants to get on that bike again. Just getting to the point of being able to walk the stairs without discomfort motivates her.

Roberta descends the stairs carefully. In one hand, she carries her Wonder Woman vintage lunchbox. It’s filled with amber vials and reflects both her sense of humor and the power she attributes to her regimen. If she can manage this, she can be Wonder Woman again. The contents of the lunchbox, however can help and hinder. Roberta learned responsible pain management through the pain clinic at Highlands Hospital after bariatric surgery, but one of her medications indicates past use of opiates.

According to Dr. Laura Miller, Chief Medical Officer for CHCN, the push to prescribe opiates began in the early 1990s. “The teaching in medical school was ‘you must treat pain.  Pain is the fifth vital sign… believe people when they talk about pain, ask them what their pain level is and get their pain to zero. You can use opiates. If people don’t have an addiction history, they will not become addicted to prescription drugs. So, crank it up.’”

The pendulum has since swung to a dangerous extreme. The number of prescriptions for opioids (like hydrocodone and oxycodone products) have escalated from around 76 million in 1991 to nearly 207 million in 2013, with the United States their biggest consumer globally, accounting for almost 100 percent of the world total for hydrocodone (e.g., Vicodin) and 81 percent for oxycodone (e.g., Percocet). (ref)

Patients like Roberta who became covered through Medi-Cal expansion, often come into the community health centers with complex, unmet health complications. They may have been self-managing their pain for years. This can mean turning to opiates they can find outside the health care system.

As Roberta’s CHCN case manager, Celina is a bridge between the hospital and the community health center. She reinforces education about prescription use while keeping open lines of communication with Roberta about her multiple physical and mental health challenges and associated medications. There’s a lot to navigate. Celina, along with Roberta’s puppy and supportive family, bridges Roberta to the future she aspires to.

In addition to helping Roberta safely manage pain, Celina is mindful of the role trauma plays in patients struggling with obesity.  “A lot of the patients that I engaged with have a long history of trauma. [By losing weight with bariatric surgery] you’ve lost that person, being stripped down, literally and figuratively. They may look for opportunities to numb this pain. If in the past what they sought was a legal substance like food… now they may be seeking something else [even if illegal] to numb the pain.”

With bariatric surgery behind her, Roberta is optimistic about taking the next step. Knee pain (resulting from her prior obesity) continues to plague her, but she is confident about undergoing total knee replacements. She’s heard about it from friends, including a former basketball player, and remains undaunted after the adjustments she’s undergone following her bariatric procedure. Regulating pain medication will be another task she and Celina will tackle together.

She shares “before and after bariatric surgery” pictures on her cell phone. The next “after” picture, she hopes, will show her riding a bike.

Help CHCN support additional patient and provider education about opiate awareness. Recently, CHCN launched a telementoring partnership for our providers through Project ECHO. Read more about Care Neighborhood’s effective case management from a prior post.